The History of Plastic Surgery, ASPS and PSEF

The Early Years

Mankind's essential nature entails self-improvement. Without the individual's pursuit of learning and enlightenment, peace with his or her neighbors and more efficient means to work, progress would stop. Because human beings have always sought self-fulfillment through self-improvement, plastic surgery -- improving and restoring form and function -- may be one of the world's oldest healing arts.

In fact, written evidence cites medical treatment for facial injuries more than 4,000 years ago. Physicians in ancient India were utilizing skin grafts for reconstructive work as early as 800 B.C.

However, progress in plastic surgery, like most of medicine, moved glacially for hundreds of years. It wasn't until the 19th and 20th centuries that the specialty forged ahead both scientifically and within the medical establishment in both Europe and the United States.

America's first plastic surgeon of note was Dr. John Peter Mettauer, who was born in Virginia in 1787. The colorful Dr. Mettauer performed the first cleft palate operation in the New World in 1827 with instruments he designed himself.

War Drives Plastic Surgery Developments

For better or worse, the driving force behind most plastic surgery developments during the late 1800s and early 1900s was war, with the awful injuries it often inflicts on its participants. In fact, it was the "War to End All Wars," World War I, that catapulted plastic surgery into a new and higher realm.

Never before had physicians been required to treat so many and such extensive facial and head injuries. Shattered jaws, blown-off noses and lips and gaping skull wounds caused by modern weapons required innovative restorative procedures. Some of the best medical talent in Britain, France, Germany, Russia and Austria-Hungary devoted themselves to restoring the faces and lives of their countrymen during and after World War I. In the United States, plastic surgeons like Varaztad Kazanjian of Boston and Vilray Blair of St. Louis nobly served both their country, and humanity, in those years.

Aesthetic Procedures Also Advance

Aesthetic surgical procedures also developed during this period as physicians realized, in the words of 19th Century American plastic surgeon John Orlando Roe, "how much valuable talent (had) been...buried from human eyes, lost to the world and society by reason of embarrassment...caused by the conscious, or in some cases, unconscious influence of some physical infirmity or deformity or unsightly blemish."

Plastic: To Mold or Give Form

Despite the popular misconception, the word "plastic" in "plastic surgery" does not mean "artificial," but is derived from the ancient Greek work "plastikos," which means to mold or give form. Plastic surgery includes both the reconstructive and aesthetic subspecialties.

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Plastic Surgeons In Need of Their Own Organization: The ASPRS

Despite the great leaps forward in plastic surgery after World War I, the profession was still rather ill-defined in the American medical establishment in the 1920s.

Physicians specializing in this area had no formal means to share their new knowledge and innovations with like-minded physicians across the country. What was needed was a professional organization.

Two Founding Fathers

Like most great American institutions, the American Society of Plastic Surgeons (ASPS) -- known until 1999 as the American Society of Plastic and Reconstructive Surgeons (ASPRS) -- developed mainly through the sweat and toil of immigrants. In this case, it was two surgeons from Europe who came to the United States after World War I, Jacques Maliniac and Gustave Aufricht.

The two doctors were as unalike as any two men could be, except for their dedication to their craft. Despite his French-sounding name, Dr. Maliniac was born in 1889 in Warsaw, Poland. After studying with the leading plastic surgeons on the continent before the war, he was called into the Russian Army at the outbreak of hostilities. A small, intense man, Dr. Maliniac, who was Jewish, came to the United States in 1923 and decided to stay as anti-Semitism was on the rise in Europe in the 1920s. Settling in New York City in 1925, he opened a thriving private practice, and convinced the administrators of the City Hospital system to establish the first division of plastic surgery at a public hospital.

Dr. Aufricht, born in 1894, was a native of Budapest, Hungary. Like Dr. Maliniac, he treated wounded soldiers during the war, studied with the leading practitioners in Europe and arrived in New York in 1923. And like Dr. Maliniac, he was Jewish and decided to stay here when things became inhospitable in the Old World. However, the similarities ended there.

Where Dr. Maliniac was considered bombastic and dictatorial with his students and residents, Dr. Aufricht, who went by the nickname "Gusti," was genial and outgoing, but no less a commanding figure, loved and revered by his charges.

ASPS is Born

The seeds of ASPS could be found in the establishment of another plastic surgery organization, the American Association of Oral Surgeons in 1921, which only accepted physicians with both medical and dental degrees and severely limited the number of members. Despite their reputations, Drs. Maliniac and Aufricht were not invited to join.

This rebuff was answered by informal meetings of Dr. Aufricht and his colleagues, including Clarence Straatsma and Lyon Peer, who plotted the formation of their own organization. Meanwhile, the decisive Dr. Maliniac acted while his colleagues talked. Dr. Maliniac met with physicians in many fields touched by plastic surgery, including Dr. Straatsma in October 1931 and invited them to join him in founding a new organization. With 10 charter members, the American Society of Plastic Surgeons was launched, with Dr. Aufricht and others joining soon after.

Board Certification

Initial ASPS meetings were held in New York, usually in Dr. Maliniac's office, and consisted of the presentation of a handful of scientific papers, often by the founder himself. An early concern of plastic surgeons was the fact that the specialty, while growing rapidly, was not recognized by the American Board of Surgeons, the medical certifying organization of the time. ASPS members were board-certified in other related specialties, such as otolaryngology (ear, nose and throat - ENT - specialists). A group of ASPS members, led by Dr. Blair of St. Louis, convinced the American Board of Surgery to establish an American Board of Plastic Surgery (ABPS) in the late 1930s. The board conducted an exam for physicians to qualify as plastic surgeons. In 1941, the ABPS came under the jurisdiction of the American Board of Medical Specialties.

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The 1940s

In the 1940s, many plastic surgeons served their country during the Second World War, and expanded plastic surgery procedures through the unique circumstances of treating wounded soldiers, sailors and airmen.

The Plastic Surgery Educational Foundation

As the 1940s moved to a close, ASPS steadily grew in membership, and by 1949 had more than 150 surgeons. These new members had been trained by surgeons other than Dr. Maliniac, who concentrated on his private practice rather than teaching. With all the new blood in the organization, Dr. Maliniac gradually lost control of his own creation. However, rather than sulking at losing his power, Dr. Maliniac moved quickly and decisively as he had done 20 years earlier in founding ASPS: in 1948, he formed the Educational Foundation of ASPS, now known as the Plastic Surgery Educational Foundation (PSEF) and served as its President until 1955.

The Foundation's mission was to support research pertaining to congenital and acquired deformities, promote high standards of training, practice and research in plastic surgery; confer scholarships and prizes; and promote lectures, seminars and medical and public meetings to educate the public in plastic surgery matters.

The Foundation also took American plastic surgery to the rest of the world by establishing exchange and fellowship programs with physicians in other nations. The PSEF has been especially active since its inception in sending American surgeons to Third World nations to help train physicians in plastic surgery techniques and treat citizens of those countries who would not otherwise have access to advanced surgical techniques. The Foundation also sponsors educational symposia to allow surgeons to demonstrate their innovations to colleagues.

The Journal

While Dr. Maliniac was launching the PSEF, Dr. Aufricht was initiating another important educational tool as well -- a scientific journal targeted specifically for plastic surgeons. With the help of Williams & Wilkins, a publishing house specializing in medical periodicals, the Journal of Plastic and Reconstructive Surgery, the official organ of ASPS, debuted in July 1946. The journal has served continuously as a forum for plastic surgeons to disseminate their knowledge and discoveries to medical colleagues for the benefit of plastic surgery patients.

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The 1950s

With board certification and its own scientific journal, plastic surgery was fully integrated into the medical establishment by 1950. It next moved into the public consciousness.

Improving Communications with the Public

In a foreshadowing of a concern that would reemerge 44 years later, ASPS President Leon Sutton, MD, called for better communication with the public, during the 1950 Annual Meeting as President Harry Truman was pushing a national health care plan. Answering the call of Dr. Sutton, plastic surgeons began to appear on a new medium, television.

New Innovations

There was much good news to report to the American people in those post-war days. As with other areas of science and medicine, plastic surgery discoveries were happening at a break-neck pace, often derived from innovations tested in the rear-area hospitals of Korea. Internal wiring for facial fractures, rotation flaps for skin deformities and a bevy of other new techniques were developed by plastic surgeons in the 1950s.

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The 1960s

As the 1960s began, plastic surgery became even more prominent in the minds of the American public as the scope of procedures performed by surgeons increased.

Discoveries

There were many scientific developments in the 1960s. A new substance, silicone, began to emerge as a tool for plastic surgeons. Silicone was initially used to treat skin imperfections, then Thomas Cronin, MD, of Houston, utilized it in a breast implant device, which he unveiled in 1962.

A Big Year for Plastic Surgery

Despite the wars on both the home front and in Vietnam in 1969, it was a big year for plastic surgery. ASPS member Hal B. Jennings, MD, of San Antonio, Texas, was appointed Surgeon General of the United States by President Nixon, the first and only plastic surgeon to date to achieve this public service honor.

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The 1970s

The 1970s began with plastic surgeons moving to the forefront of the medical profession. All parts of the human body, it seemed, could benefit from the skill of a plastic surgeon and ASPS members made landmark contributions in areas not previously considered within their sphere.

A Nobel Laureate

In the early 1970s, ASPS member Joseph Murray, MD, of Boston, performed the first successful kidney transplant, an achievement that would earn him the Nobel Prize. Another ASPS member, George Crikelair, MD, of Florida, developed flame-retardant children's clothing, saving thousands of lives, and thousands more from agonizing pain and disfigurement.

The Passing of a Founding Father

In 1976, ASPS founder Jacques Maliniac passed away. In the 45 years since he founded the Society, he had seen it grow from a handful of his east coast New York colleagues to nearly 2,000 members spread across the country.

Conflict with Uncle Sam

The Federal Trade Commission (FTC) gave ASPS a different sort of bad news a few months later. The FTC informed the Society that it had to surrender certain records to the government.

The Commission was on an anti-medicine kick. It had already strong-armed the AMA into allowing doctors to advertise, and now had turned its attention to plastic surgery, which was a relatively small specialty, but prominent in the public's eye.

FTC Commissioner Michael Pertschek considered medical boards and board certification self-serving and anti-competitive, although they generally assured patients of the best quality physicians. He hoped to sweep out the system and initiate advertising and price-wars among medical professionals. However, after a long battle with the Society, the FTC eventually backed down.

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The 1980s

Although the FTC lost the battle, plastic surgery got the message: Operate more like a regular business for the good of the patient.

Keeping the Patient Informed

The 1980s saw plastic surgery expand its efforts to bring knowledge and information to the public. Studies indicated that patients wanted information to take home and read, so ASPS began producing a host of brochures on the specialty and individual plastic surgery procedures.

Another Pillar Falls

The other founding pillar of the ASPS, Gustave Aufricht, passed away in April 1980, one year short of the organization's 50th anniversary.

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The 1990s

The 1990s began on a high note of growth, cooperation and continued innovations in the field of plastic surgery. More than 5,000 board-certified plastic surgeons were active in the United States. Many were engaged in research or volunteered in their communities or overseas.

The Internet

In 1995, ASPRS unveiled "Plastic Surgeons Online," a subscription-Web service where plastic surgeons were able to post questions about difficult cases and receive responses from their peers around the world. It also hosted its first cyberspace surgical conference (on rhinoplasty). These tools were nothing short of revolutionary at the time, but merely the tip of the iceberg of what was to come.

In 1996, the Society launched its first public Web site www.plasticsurgery.org, while the world wide web was still in its infancy. The Society offered the largest library of plastic surgery procedural information on the Internet, and included listings of its members in the ASPS "Find a Plastic Surgeon" online referral service.

Public Perceptions Need Improvement

Despite the contributions plastic surgeons make both in their own communities and the world community, the profession suffered from an identity problem as consumers didn’t recognize the broad spectrum of work plastic surgeons perform. A survey conducted by ASPS in the early '90s indicated that the American people did not realize plastic surgeons perform reconstructive work, instead equating "plastic surgeon" with "cosmetic surgeon."

In 1994, ASPS President Elvin G. Zook, MD, of Springfield, IL, made changing this perception one of the top priorities of his tenure. He promoted changing the name of the Society from American Society of Plastic and Reconstructive Surgeons (ASPRS) to American Society of Plastic Surgeons (ASPS) in an effort to convince people that plastic surgeons and reconstructive surgeons are one and the same, not two different types of surgeon, as the old name of the society seemed to imply.

His initiative took five years to win enough support to pass, but in 1999, the society officially became the American Society of Plastic Surgeons.

Silicone Implants Come to Crisis in the '90s

In 1976 the Food and Drug Administration (FDA) was given the authority by Congress to regulate medical devices. That same year, the FDA's General and Plastic Surgery Devices Panel recommended that breast implants be classified as class II medical devices, requiring general controls and performance standards.

Throughout the 1980s, the issue went largely unnoticed by the public. However, in 1988, the FDA announced classification of breast implants as class III devices and indicated that the agency could require manufacturers to submit studies on implant safety and effectiveness.

In early 1989, an unpublished study on polyurethane foam-covered implants raised FDA concern about the product's safety, and the manufacturer removed the device from the market.

In December 1990, the questions of implant safety exploded nationally when "Face-to-Face with Connie Chung" detailed the "horrors" of breast implants. Her report sparked a wave of concern among women with breast implants and increased pressure on government officials to act.

Plastic surgeons sought to reassure breast implant patients and the public. ASPS and PSEF provided the FDA with much information on the positive clinical experience of plastic surgeons and their patients, including a survey that indicated more than 90 percent of implant patients were satisfied with their devices. ASPS set up a toll-free hotline for physicians and patients with questions about implants.

Despite the efforts of the Society and Foundation to address growing fears scientifically, the FDA called for a temporary moratorium on the use of silicone gel breast implants in January 1992. In April of that year, the agency announced that silicone gel implants would only be available to women for reconstruction under clinical studies, in essence removing them from the open market.

While ASPS and PSEF continued to fund research to provide patients with the answers they deserved on the safety and efficacy of their implants, a $4 billion plus global litigation settlement was unveiled in September 1993. The settlement was created by the manufacturers of silicone breast implants to address a class action suit brought by women plaintiffs who alleged the implants caused them illness.

The Federal Court gave approval to the settlement in September 1994. By the fall of 1995, however, the settlement, as originally proposed, had collapsed due to underfunding following the bankruptcy filing of Dow Corning Corp.

Despite a growing volume of studies published in the scientific literature, an extensive government-funded study conducted by the prestigious Institute of Medicine on the safety of breast implants released in June 1999, and a late 1998 report from the federal court-appointed National Science Panel, all of which found no connection between the implants and illness in women, a revised settlement was eventually agreed upon.

In 2000, the fund began issuing checks to women who had registered for the settlement alleging sickness as a result of their implants.

Health Care Reform

The other great challenge of the 1990s was health care reform. Plastic surgeons were active in advocating for coverage for reconstructive procedures in any new health plan and ensuring patient choice and access to specialists.

In 1998, after an extensive lobbying effort, President Clinton signed a budget bill which included a long sought-after provision requiring insurance companies to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy.

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The 2000s

The 2000s have continued unusually rapid growth and change in plastic surgery. This pace reflected the increasing speed of communication, but many innovations were reactions to decisions made by state and federal governments.

Decreasing Insurance Reimbursement Leads to Increasing Focus on Cosmetic Procedures

By performing more cosmetic surgery and becoming less dependent on insurance payments, plastic surgery remained uniquely independent. By 2005, the most popular procedure of the specialty was the use of injectable substances to address the effects of aging, as patients sought less invasive, simpler operations to reduce wrinkles.

Following the FDA's approval of Botox® in 2002, ASPS members performed an average of 1.1 million such injections a year through 2006.

By the mid-2000s, surgeons were still losing ground on the critical issue of reimbursement. Payment from third-party payers reached such low levels that many established surgeons rejected the premise they could ever again maintain a practice based solely on reimbursement from reconstructive cases.

The national news resounded with stories about the flight of many surgical specialists from specific locales due to the combination of exorbitant malpractice premiums coupled with steadily decreasing insurance reimbursement.

Shift to Proactive Involvement in Politics

If the prolonged controversy over breast implants was not lesson enough, other pressures taught plastic surgeons they could no longer avoid participation in politics. In response to newspaper reports in 1999 on the deaths of 10 patients who underwent cosmetic procedures in the offices of surgeons in Florida, the state’s Board of Medicine declared a 90-day moratorium on office-based surgery.

In 2000, the ASPS convened the Task Force on Patient Safety and Office-Based Surgery Facilities to review, among other areas, identification and evaluation of risk factors. The same year the society’s Board of Directors amended its bylaws to require that by July 1, 2002, all members performing surgery under anesthesia do so in only accredited, licensed or Medicare-certified surgical facilities.

The ASPS Government Affairs Committee created regional, fly-in meetings to the nation’s capitol in 2001 and the Society opened an office in Washington, D.C., in 2004 to increase plastic surgery’s visibility and ability to build coalitions on the Hill.

Through necessity and experience, ASPS developed the ability to respond immediately – in any of the 50 states or the nation’s capital – to new mandates or regulations unfriendly to plastic surgery and its patients.

During 2002, the Society also began to emphasize participation in advocacy for members by identifying two or three people in every state who could monitor problems and act as the "front people" should they arise. The specialty knew that if was going to be able to continue to serve patients in the future, it had to become more aware of what medical discussions were occurring in the legislature.

One of the themes of both the '90s and 2000s has been the increased need for legislative monitoring of bills that impact the practice of medicine, whether they address scope of practice or physician taxation.

In 2004, New Jersey enacted the first-ever tax on cosmetic surgery. For years government had cut reimbursement for reconstructive procedures, and now it sought to reduce payment for elective procedures – the very thing that had allowed many plastic surgeons to stay in practice and pay their bills.

Over the following months, ASPS led a coalition that successfully blocked similar bills in six other states. Within two years, New Jersey’s lawmakers realized that their bill had been ill-advised, and began investigating how to repeal their disappointingly low-revenue tax.

Public Perceptions Improve

In 1996, ASPRS launched the Plastic Surgery Education Campaign – a national public awareness campaign that sought to educate the public on the importance of choosing a plastic surgeon certified by the American Board of Plastic Surgery.

At the time, the Society’s leaders could not have envisioned the transformation in public image that plastic surgery would undergo in the following decade thanks to an escalating amount of media attention.

In 2000, W magazine compiled a list of the specialty’s 41 "surgery superstars." ASPS members appeared on television, were quoted increasingly in all the major health and beauty magazines, and even provided data for National Geographic.

In 2003, ABC-TV asked ASPS to allow its members to participate in the reality series "Extreme Makeover."

The request raised a substantial ethical debate among plastic surgeons, but ultimately after reviewing the patient selection process of the show, the Society’s Executive Committee agreed to cooperate with the producer and network so long as the importance of the doctor-patient relationship was not lost and that the show’s patient selection process did not devolve into a contest.

The series' instant popularity opened the floodgates to a flurry of TV shows about plastic surgery, most of which did not live up to the high standards or positive plastic surgery image of "Extreme Makeover."

Not surprisingly, thanks to the combination of magazine coverage, the ASPS public education campaign and the television saturation of shows revolving around plastic surgery, interest in the specialty and what it offered the general public grew exponentially.

In 2003, more than 8.7 million cosmetic procedures were performed, 32 percent more than in 2002. Over the same time period, ASPS members performed 64 percent more procedures involving injectables.

By 2004, 14.8 million plastic surgery procedures were performed in the U.S. And by 2006, that number had risen to 16.2 million.

FDA Approves Reintroduction of Silicone Breast Implants

On Nov. 17, 2006, some 14 years after the start of the moratorium on silicone gel-filled breast implants, the FDA approved the return of silicone implants to the market for general patient use. This was the culmination of an ongoing study and review process that began in the early '90s.

During this period, the FDA also reviewed saline implants, which remained on the market during the moratorium on silicone. In 1999, following the regulatory process laid out years earlier, the FDA called for a review of safety and effectiveness data on saline-filled breast implants.

In 2000, following hearings and clinical study review, the FDA approved the study data submitted by two saline implant manufacturers, recognizing that saline-filled breast implants earned high satisfaction ratings by implant recipients, despite local complications.

Hearings and discussions on the safety of silicone gel-filled breast implants were held throughout the first half of the decade, and in 2005, the FDA granted silicone implants the status of "approvable with conditions."

It would take another year, but finally, at the end of 2006, silicone implants were returned to the market. More than a decade of inquiry, testimony and an expansive body of science all supported the safety of the implants, which will continue to be monitored by clinical studies in the years ahead.

Future Challenges

Plastic surgeons were able to get Congress to support mandatory insurance coverage for breast reconstruction patients in the '90s and are currently working to ensure that reconstructive surgery for treatment of children's deformities will also be covered by insurance plans.

Meanwhile, plastic surgery – always a specialty that has thrived on innovation – continues to push ahead with new clinical breakthroughs, refining current techniques and discovering new ones.

Plastic surgeons are researching methods to reduce surgical scarring and patient recovery time. They are devising new outcomes studies to prove with comprehensive data the quality of life improvements that plastic surgery provides via its vast array of procedures.

And some researchers are now trying to unlock the secrets of the growth-factor environment of the womb, where scarless healing takes place, so that this knowledge can be applied to wounds in children and adults.

The future of plastic surgery continues to unfold, with the promise of amazing new things to come, in the humanitarian pursuit to help patients look and feel their best!

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